Switching during treatment: what happens to cost approvals

Switching despite ongoing treatment: the rules

Many people stay with a more expensive health insurer because therapy is under way, an operation is planned or a medicine is being paid for with special approval. The worry is that the new insurer might reject them or stop paying for the treatment. In basic health insurance, the first worry is unfounded; the second requires some preparation.

• Acceptance: Every health insurer must accept you in its area of activity (Art. 5 let. i of the Health Insurance Supervision Act, KVAG). This obligation to accept applies regardless of age and health. The FOPH states that the insurer may not require a health questionnaire for basic health insurance.
• Benefits: Basic health insurance pays the same statutory benefits with all insurers. An insurer may not cover any costs other than those named in the law (Art. 34 para. 1 of the Federal Health Insurance Act, KVG).
• Responsibility: Which insurer pays is decided by the date of treatment (Art. 103 para. 3 of the Health Insurance Ordinance, KVV). Up to the last day before the switch, the old insurer is responsible; from the day of the switch, the new one.
• Cost approvals: A cost approval is a commitment by an insurer to its own insured persons. The KVG and KVV contain no provision binding the new insurer to the old insurer’s commitment. For the period from the switch, you therefore submit a new request.

The table shows the most common cases in basic health insurance. Whether your treatment needs an approval is something the treating practice knows; ask there before you cancel.

Step by step: switching health insurer during ongoing treatment

1. Clarify the treatment plan. Ask the practice which treatments are planned after 1 January and whether any of them needs a cost approval. Find out who submits the request; it is usually the doctor or the hospital.
2. Choose the new insurer and model. Compare premiums in the premium calculator. Pay attention to the model: in a GP, HMO or telemedicine model, you restrict your free choice of service providers (Art. 41 para. 4 KVG). Before registering, check whether your therapist or doctor fits the model and whether you need a referral.
3. Cancel and register. Your notice of cancellation of basic health insurance must reach the old insurer by 30 November (Art. 7 para. 2 KVG). The FOPH recommends sending it by registered mail or A Mail Plus by 15 November. At the same time, you register with the new insurer.
4. Apply for approval from the new insurer. As soon as your acceptance has been confirmed, ask the practice to submit the request for the period from 1 January to the new insurer. For an off-label medicine, the insurer decides on a complete request within two weeks (Art. 71d para. 3 KVV). So do not submit it only in the last days of December.
5. File the commitment in writing. Keep the new insurer’s approval together with the confirmation of cancellation.
6. Pass on your new health insurance card. From 1 January, you show the practice, pharmacy and hospital the new insurer’s card. Bills for treatment up to 31 December still go to the old insurer.
7. Do not cancel supplementary insurance hastily. More on this in the section below.

Cost approval and medical adviser: what the rules require

Basic health insurance pays for most benefits without prior commitment if they are effective, appropriate and cost-effective. You only need an approval where the law or an ordinance requires one. The insurer’s medical adviser then examines the application. After the switch, that is the medical adviser of the new insurer.

Off-label medicines. Basic health insurance only covers them with special approval from the insurer after prior consultation of the medical adviser (Art. 71d para. 1 KVV). If the insurer refuses, it must give reasons for its decision to the doctor and the patient (Art. 71d para. 6 KVV). Because each insurer decides for itself, the outcome may be different with the new insurer. For such treatment, clarify before cancelling whether the new insurer can examine a request in time.

Physiotherapy. The insurer pays for at most nine sessions per medical prescription; the first must take place within five weeks of the prescription (Art. 5 para. 2 of the Health Care Benefits Ordinance, KLV). Further sessions require a new prescription. If therapy is to continue after 36 sessions, the doctor reports to the medical adviser, who assesses whether it should continue (Art. 5 para. 4 KLV). The prescription is not a commitment by the insurer; it remains valid after the switch.

Psychotherapy. For psychotherapy by a doctor, the doctor reports to the medical adviser after 40 sessions; within 15 working days, the insurer states whether and for how long it will continue to pay (Art. 3b KLV). For psychological psychotherapy on medical prescription, this procedure applies after 30 sessions (Art. 11b para. 3 KLV). If such a report is due around the turn of the year, it is worth submitting it to the new insurer.

Planned procedures. For certain procedures, basic health insurance only pays for inpatient treatment if outpatient treatment is not appropriate or not cost-effective. If none of the criteria in the ordinance applies, a special approval is needed in advance (Art. 3c KLV). If the operation is planned for January, the hospital obtains the approval from the new insurer.

Example: switching with physiotherapy in the standard model

Example with fictitious people. Sandro is 52, lives in Bern and has had regular physiotherapy on medical prescription since October. He is insured in the standard model with a CHF 300 deductible and pays a premium equal to the median of the standard offers in his municipality.

The calculation compares premiums, not benefits: these are the same in both cases. Which model suits you depends on how you use doctors and therapies; the models are explained on the page Insurance models. The FOPH publishes next year’s premiums at the end of September.

Supplementary insurance: where treatment can become an obstacle

In supplementary insurance, there is no obligation to accept. The new insurer may ask you health questions before concluding the contract, and you must answer them truthfully (Art. 4 of the Insurance Contract Act, ICA). Ongoing treatment can lead to a reservation or a rejection.

The good news: you do not have to switch your supplementary insurance. The old insurer may not force you to cancel it together with basic health insurance, and it may not cancel it because you switch (Art. 7 para. 7 and 8 KVG). The ordinary right of cancellation in supplementary insurance is yours alone (Art. 35a para. 4 ICA). So you can switch basic health insurance and keep your supplementary insurance with the old insurer. What counts for benefits and notice periods are the general terms and conditions and the information from your insurer.

Special cases

• Hospital stay over the turn of the year. If you are in hospital from December into January, clarify in writing with both insurers before switching who will settle the stay.
• Switching during the year. If you switch because you move or on 1 July, the new insurer credits the deductible and retention fee already invoiced in the current year (Art. 103 para. 4 KVV). The 1 July date only exists in the standard model with a CHF 300 deductible, with receipt of the notice of cancellation by 31 March (Art. 7 para. 1 KVG).
• Switching to a cheaper model. From the standard model, you can switch to a model with restricted choice at any time, but back only at the end of the year (Art. 100 para. 2 and 3 KVV). Check this particularly carefully if your treatment is long.
• Unpaid premiums. If premiums or co-payments for which you have received a reminder are unpaid, you cannot switch until everything has been paid. How you can still leave your old insurer is explained in the article Unpaid premiums and switching health insurer.

If the new health insurer rejects the approval

If the new insurer rejects a request, ask for a written decision. The insurer must issue a written decision on benefits with which you do not agree (Art. 49 para. 1 of the Federal Act on the General Part of Social Insurance Law, ATSG). You can lodge an objection against the decision with the insurer within 30 days (Art. 52 para. 1 ATSG). The Office of the health insurance ombudsperson advises you on this free of charge.

Common mistakes

• Not comparing at all because of the treatment. In basic health insurance, every insurer must accept you, and the benefits are the same. You can find the insurers’ key figures and contact channels in the health insurer profiles.
• Assuming the approval moves with you. For treatment from the day of the switch, submit a new request to the new insurer.
• Submitting the request only in January. The insurer has deadlines for its examination; submit the request as soon as your acceptance has been confirmed.
• Choosing a cheaper model without checking the treatment. If you do not follow the rules of the model, you risk reductions.
• Cancelling supplementary insurance as well. You can switch basic health insurance on its own; your supplementary insurance stays if you do not cancel it.

The procedure for switching with all dates is shown by the deadline calculator. Why switching does not result in double basic health insurance is explained in the article Double insurance. You can find all articles on the subject in the topic section Switching health insurer. More on changing health insurer is in the glossary.